NYC06FA004

NTSB accident investigation · Beech A36 · Pikeville, KY · October 7, 2005

Accident · FatalField investigationFinal report
Date
October 7, 2005, 15:51 local (19:51 UTC)
Place
Pikeville, KY
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N97CMBeech A36
Weather
Instrument (IMC) · Day
Status
Completed · report October 31, 2006
Report
Approved by Office Director
Parties
FAA FSDO-01, Teledyne Continental Motors, Raytheon Aircraft Company
FAA report
20051007024919A
Case key
62625

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to follow the published instrument approach which resulted in controlled flight into terrain. A factor was the low ceiling.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterApproach - faf/outer marker to threshold (ifr)
Weather condition - low ceilingFactor
Ifr procedure - not followedPilot in commandCause
Terrain condition - mountainous/hilly

Analysis

The instrument rated pilot had received a weather briefing, which included a forecast ceiling of 700 feet and visibility of 4 miles. He then filed an instrument flight plan, and proceeded uneventfully to the destination airport area. He remained in communication with air traffic control, and complied with their instructions, while flying a precision approach to runway 27. However, about 1 mile from the runway threshold, the airplane flew left of the localizer course and below decision height. The airplane subsequently impacted mountainous terrain about 1 mile south of the airport. Weather at the time was oscillating above and below minimums for the instrument approach, which required a ceiling of 200 feet and visibility of 3/4-mile. The published missed approach procedure included a climb to 3,000 feet and then a left climbing turn to 4,000 feet msl. Examination of the wreckage did not reveal any pre-impact mechanical malfunctions, nor did the pilot report any to ATC.

Factual narrative

History of flight

On October 7, 2005, at 1551 eastern daylight time, a Beech A36, N97CM, was destroyed when it impacted mountainous terrain, while on approach to Pike County Airport (PBX), Pikeville, Kentucky. The certificated private pilot and two passengers were fatally injured. Instrument meteorological conditions prevailed for the flight that departed Barkley Regional Airport (PAH), Paducah, Kentucky, about 1345. An instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 CFR Part 91.

According to information from the Federal Aviation Administration (FAA), the pilot telephoned the Louisville, Kentucky Automated Flight Service Station (AFSS), about 1215. The pilot advised the AFSS specialist of his intended flight, and asked about "echoes" in the Eastern Kentucky area.

The specialist advised of light to moderate rain over the central portion of the planned route, and at PBX. The specialist also provided current and forecast weather conditions along the planned route of flight. The provided forecast for Eastern Kentucky was: ceiling 700 feet broken; 1,500 feet overcast; visibility 4 miles in light rain and mist; wind northerly at 5 knots; valid for the rest of the daylight hours. The pilot then filed an IFR flight plan, but did not list an alternate destination airport.

The flight proceeded uneventfully to the Pikeville area, and the pilot was in radio contact with Indianapolis Air Route Traffic Control Center.

At 1527, the pilot advised air traffic control (ATC) that he had the current weather conditions at Pikeville, and requested the ILS Runway 27 approach. ATC then began to vector the flight for the approach.

At 1546, ATC cleared the flight for the ILS Runway 27 approach, and the pilot acknowledged the clearance.

At 1548, the pilot reported established on the localizer course. ATC then approved a change in radio frequency, and requested the pilot cancel his flight plan on the current radio frequency, or through relay with another aircraft.

At 1548, the pilot acknowledged the transmission, and no further communications were received from the accident airplane.

The airport elevation was 1,473 feet msl, and the decision height for the approach was 1,664 feet.

At 1550:40, a radar target indicated the airplane was at 2,300 feet msl, about 1 mile from Runway 27 threshold. The four subsequent radar targets indicated that the airplane traveled left of course.

At 1551:20, radar contact was lost, as the airplane descended below 1,800 feet msl. At that time, the target indicated the airplane was about 1 mile south of the airport, near the accident site.

The wreckage was located about 4 hours later, approximately 1 mile south of runway 27.

Witnesses at and near the airport reported hearing the sound of continuous engine noise, followed by the sound of impact. One witness was a the pilot of a Cessna Citation Encore, that landed at PBX about 1530. He reported that a that time, the ceiling was 230 feet agl; however, after landing, he observed the weather conditions oscillate above and below the minimum conditions required for the approach. The witness then heard:

"N97CM coming down the ILS. A few seconds later, at what I think was near DH, the aircraft sounded like it was going south of the airport, at approach speed, approach power settings, and either level or a slight descent until we could not hear him anymore...I did not hear the impact."

Another witness, who was a helicopter pilot, was performing maintenance tests on the ground at PBX. The witness reported that the ceiling was 200 to 300 feet overcast, and visibility was at least 3/4-mile. The witness further stated that the weather had been deteriorating all day. He heard an airplane fly past the airport to the south, "It sounded normal and we assumed he did the approach, missed, and performed a missed approach...We never heard the sound of the crash."

The accident occurred during the hours of daylight; located 37 degrees, 32.84 minutes north latitude, and 82 degrees, 34.22 minutes west longitude.

Personnel information

The pilot held a private pilot certificate, with ratings for airplane single engine land and instrument airplane.

The last entry in the pilot's logbook was dated July 24, 2005. At that time, the pilot recorded a total flight experience of approximately 527 hours. The pilot also recorded about 323 hours of actual instrument experience; however, a review of an excerpt from the logbook revealed that the pilot logged all of the flight time as "actual instrument."

His most recent FAA third class medical certificate was issued on June 24, 2005.

Aircraft information

The aircraft logbooks were not recovered. Review of maintenance records from an aircraft repair facility revealed that the airplane received an annual inspection on February 22, 2005. At that time, the airplane had accumulated 2,593.4 total hours of operation.

Meteorological information

The reported weather at PBX, at 1544, was: wind from 330 degrees at 7 knots; visibility 4 miles; scattered clouds at 300 feet; broken ceiling at 2,100 feet; temperature 19 degrees C; dew point 18 degrees C; altimeter 29.81 inches Hg.

The reported weather at PBX, at 1556, was: wind from 330 degrees at 7 knots; visibility 3/4 miles; overcast ceiling at 200 feet; temperature 18 degrees C; dew point 18 degrees C; altimeter 29.81 inches Hg.

A pilot report (PIREP) was received from the pilot of a Cessna 560, over PBX at 1655. The report included and indefinite ceiling, with remarks that the ceiling was less than 100 feet and the flight visibility was less than 100 feet.

Aerodrome information

The airport was serviced by runways 9/27 and 2/20. Runway 27 was 5,350 feet long, 100 feet wide, and consisted of asphalt. Runway 27 was equipped with runway end identifier lights and medium intensity runway lights.

Review of an FAA instrument approach procedure chart, for the ILS Runway 27 approach at PBX, revealed that the airport elevation was 1,473 feet msl. The decision height (DH) for the approach was 1,664 feet msl, which was 200 feet above the touchdown zone elevation. The minimum visibility required for the approach was 3/4-mile.

The missed approach procedure stated, "Climb to 3000 then climbing left turn to 4000 direct AZQ VOR/DME and hold."

A Notice to Airmen (NOTAM) was in effect for runway 9/27 markings.

Wreckage and impact information

The wreckage was examined at the accident site on October 9, 2005, and all major components of the airplane were accounted for at the scene. The main wreckage was resting about 100 feet below the peak of a mountain. The wreckage was oriented about a northerly heading, at an elevation of approximately 1,520 feet. A debris path was observed, which consisted of severed trees, and extended about 100 feet to the main wreckage. The trees were severed about the same height, oriented about a 270-degree heading to the main wreckage. Fragments from the right wingtip were located on the right side of the debris path, and fragments from the left wingtip were located on the left side of the debris path. A majority of the main wreckage, including the cockpit and cabin, was consumed by a post-crash fire.

The right wing, right wing flap, and right wing aileron sustained impact damage. The inboard portion of the right wing remained partially attached to the fuselage, and the right flap remained partially attached to the inboard section of right wing. The right aileron also remained partially attached to the right wing. Flight control continuity was confirmed from the cockpit to the right aileron bellcrank. The bellcrank had separated consistent with overload. A measurement of the right wing flap actuator revealed that the flaps were in the fully retracted position. The outboard portion of the right wing was located ab

Aircraft

Registration
N97CM
Reported as
Beech A36
Category
Airplane
Serial number
E-1119
Airframe hours
2,593
Engine
Continental IO-520, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Herman W Lester
Registered owner
Bethlehem Investments Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2005
Departed
PAH · Paducah, KY
Destination
PBX · Pikeville, KY
Flight plan
IFR
Airport
PBX · Pikeville County Airport, runway 27, 5,350 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
527 total · 467 as pilot in command

Weather

Conditions
Instrument (IMC) · Day
Wind
330° at 7 knots
Visibility
0.75 statute miles
Lowest ceiling
200 ft overcast
Temperature
64 °F, dew point 64 °F
Altimeter
29.80 inHg
Observed at
PBX, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.